A nurse is assessing a client who has delirium.
Which of the following findings requires immediate intervention by the nurse?

Command hallucinations.

Impaired memory.

Inappropriate speech patterns.

Rapid mood swings.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Command hallucinations require immediate intervention by the nurse. Command hallucinations are auditory hallucinations in which the client hears voices instructing them to perform specific actions, often harmful or dangerous. These hallucinations can lead to the client engaging in harmful behaviors or self-harm. The nurse must address this symptom promptly to ensure the client's safety and well-being.

Choice B rationale:

Impaired memory is a common symptom in clients with delirium, but it does not require immediate intervention. While impaired memory can be distressing for the client, it is not an immediate safety concern. The nurse should address memory deficits as part of the overall care plan but prioritize more urgent issues like command hallucinations.

Choice C rationale:

Inappropriate speech patterns are also common in clients with delirium. While they may be concerning, they do not typically pose an immediate risk to the client's safety. The nurse should assess and address inappropriate speech patterns but prioritize the safety of the client, especially when command hallucinations are present.

Choice D rationale:

Rapid mood swings are a symptom of delirium but, like impaired memory and inappropriate speech patterns, do not require immediate intervention to the same extent as command hallucinations. The nurse should address mood swings as part of the overall care plan and ensure that the client's safety is not compromised due to their condition.

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Correct Answer is D

Explanation

Choice A rationale:

Hypothyroidism is not directly related to the use of bupropion for smoking cessation. It is essential to consider the client's overall health, but in this context, it is not the most significant concern, so it does not need to be reported immediately.

Choice B rationale:

Knee arthroplasty one month ago is not a contraindication for bupropion use, but it is essential to consider postoperative precautions and mobility. However, it is not the most critical issue related to the client's request for smoking cessation medication, so it does not need immediate reporting.

Choice C rationale:

Hepatitis B infection is a concern but does not necessarily contraindicate the use of bupropion. The nurse should address this issue, but it is not the most urgent concern for the client's request for smoking cessation medication.

Choice D rationale:

Reporting a recent head injury is crucial because bupropion is contraindicated in clients with a history of seizures or conditions that lower the seizure threshold, such as recent head trauma. Seizures are a significant potential side effect of bupropion, and a recent head injury could increase the risk of seizures. Therefore, the nurse should report this finding immediately to ensure the client's safety.

A. "How do you think this event is affecting your life right now?". B. "Are you having thoughts about harming yourself?". C. "What do you usually do to cope with problems in your life?". D. "Who do you talk to when you need help?".

Correct Answer is B

Explanation

Choice A rationale:

Asking how the event is affecting the client's life is important, but it is not the priority during a situational crisis. Safety and assessing for self-harm thoughts come first.

Choice B rationale:

This question is the priority because it assesses the client's safety and potential for self-harm, which is crucial during a crisis. If the client is having thoughts of self-harm, immediate intervention is required.

Choice C rationale:

Inquiring about the client's coping strategies is relevant, but it is not the primary concern when there is a potential risk of self-harm.

Choice D rationale:

Asking about who the client talks to for help is important but not the primary concern in a situation where self-harm may be a risk.

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A nurse is assessing a client who has delirium.Which of the following findings requires immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is obtaining a medical history from a client who is requesting a prescription for bupropion for smoking cessation.Which of the following assessment findings in the client's history should the nurse report to the provider?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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A nurse is assessing a client who has delirium.
Which of the following findings requires immediate intervention by the nurse?